CLEFT LIP & CLEFT PALATE
DR. RYAN FERNANDES
ASST. PROFESSOR
DEPARTMENT OF SURGERY
Development of Face
Face develops from the
 Median nasal process
 Lateral nasal process
 Maxillary process
 Mandibular arch
 Globular arch
 Olfactory pit & eye
Any change in the development or fusion of these arches
leads to formation of different types of cleft lip or cleft
palate
INCIDENCE
 Common in caucasians
 75% cases- unilateral
 Commonly occurs on the left side
 50% cases – combined cleft lip & palate
 Common in boys
 15- 25% of cases cleft lip alone
 25-40% of cases cleft palate alone
Aetiology
 Familial – more common in cleft lip or combined cleft lip
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& palate
Protein & vitamin deficiency
Rubella infection
Radiation
Chromosomal abnormalties
Maternal epilepsy & drug intake during pregnancy
(steroid/ eptoin/ diazepam)
CLEFT LIP
 Central – rare
 Seen in upper lip between 2 medial nasal processes (Hare
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Lip)
Lateral -maxillary & median nasal processes,
commonest, can be unilateral or bilateral
Incomplete cleft lip does not extend into the nose
Complete cleft lip extends into the nasal floor
Simple cleft lip is only the cleft in the lip
Compound cleft lip is cleft lip with cleft of the alveolus
Anatomy Of Cleft Lip
 Occurs due to disruption
of muscles of the upper
lip & nasolabial region.
 The facial muscles are
divided into 3 muscular
rings of Delaire –
1. Nasolabial muscle ring
2. Bilabial muscle ring
3. Labiomental muscle
ring
Unilateral Cleft Lip
 Nasolabial & bilabial muscle rings are disrupted on one
side.
 Results in asymmetrical deformity involving the external
nasal cartilages, nasal septum & anterior maxilla.
 These deformities influence the mucocutaneous tissues
causing a displacement of nasal skin onto the lip as well
as changes to the vermillion & lip mucosa
Unilateral Cleft Lip
Bilateral Cleft Lip
 Here the deformity is more profound but symmetrical.
 The two superior muscular rings are disrupted on both
sides producing a flaring of the nose, a protrusive pre
maxilla & an area of skin in front of the pre maxilla
devoid of muscle known as prolabium.
Bilateral Cleft Lip
CLEFT PALATE
 It is due to failure of fusion of two
palatine processes.
 Defect in fusion of lines between
pre-maxilla (developed from
median nasal processes) &
palatine processes of maxilla one
on each side.
 When premaxilla & both palatine
processes do not fuse, it leads into
complete cleft palate(Type I cleft
palate)
 Incomplete fusion of these 3 components can cause
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incomplete cleft palate beginning from uvula towards
posteriorly at various lenghts
So it could be –
Type II a – bifid uvula
Type II b – bifid soft palate
Type II c – bifid soft palate & posterior part of hard
palate.
 Small maxilla with crowded teeth, absent/poorly
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developed upper lateral incisors
Bacterial contamination of upper respiratory tract with
recurrent infection is common.
Chronic oitits media with deafness may occur
Swallowing difficulties to certain extent & speech
problems may occur.
Cosmetic problems may occur.
Cleft Palate
 Embryologically, the
primary palate consists of
all anatomical structures
anterior to the incisive
foramen, namely the alveolus
and upper lip.
 The secondary palate is
defined as the remainder of
the palate behind the incisive
foramen, divided into the hard
palate and, more posteriorly,
the soft palate.
 Cleft palate results in failure of fusion of the two palatine
shelves.
 This failure may be confined to the soft palate alone or involve
both hard and soft palate.
 When the cleft of the hard palate remains attached to the nasal
septum and vomer - incomplete.
 When the nasal septum and vomer are completely separated
from the palatine processes - complete
Soft palate
 The muscle fibres of the soft
palate are orientated
transversely with no significant
attachment to the hard palate.
 In a cleft of the soft palate the
muscle fibres are orientated in
an anteroposterior direction,
inserting into the posterior
edge of the hard palate
Hard palate
 The normal hard palate can be divided into three
anatomical and physiological zones.
 The central palatal fibromucosa is very thin and lies
directly below the floor of nose.
 The maxillary fibromucosa is thick and contains the
greater palatine neurovascular bundle.
 The gingival fibromucosa lies more lateral and adjacent
to the teeth.
Classification
I.
II.
III.
IV.
V.
Cleft lip alone
Cleft of primary palate
Cleft of secondary palate
Cleft of both primary & secondary palates
Cleft lip & cleft palate together
I.
Cleft lip alone
Unilateral
Bilateral
Median
II. Cleft of primary palate only
This lies in front of the incisive
foramen.
a. Complete – absence of pre maxilla
b. Incomplete – rudimentary pre
maxilla
i.
ii.
iii.
Unilateral
Bilateral
Median
III. Cleft of secondary palate only
This is the cleft which lies behind the incisive foramen
a. Complete – nasal septum & vomer are separated from
palatine process
b. Incomplete
c. Submucus
It can be - cleft with soft palate involvement
cleft without soft palate involvement
 Defect is often associated with other congenital anomalies
–
 Pierre-Robin syndrome – isolated cleft palate,
retrognathia, posteriorly displaced tongue.
 Klippel Feil syndrome,Stickler’s syndrome(eye,
skeletal,muscular,cleft disorder)
Problems in cleft disorders
 Difficulty in sucking & swallowing
 Speech is defective especially in cleft palate mainly to
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phonate B,D,K,P,T & G.
Recurrent upper respiratory tract infection
Chronic otitis media, middle ear problems
Altered dentition or supernumerary teeth
Respiratory obstruction
Cosmetic problems
Primary Management
Antenatal diagnosis
 An antenatal diagnosis of cleft lip, whether unilateral or
bilateral, is possible by ultrasound scan after 18 weeks of
gestation.
 Isolated cleft palate cannot be diagnosed by antenatal
scan.
 When an antenatal diagnosis is confirmed, referral to a
cleft surgeon is appropriate for counselling to allay fears.
Antenatal (Contd)
 Photographs of cleft lip shown to parents ‘before and
after’.
 Introduction to a parent support group and meeting
parents of a child with a similar cleft who has
undergone surgery
Feeding
 Most babies born with cleft lip and palate feed well and
thrive, provided that appropriate advice is given and
support is available.
 Some mothers are successful in breastfeeding, particularly
when the cleft is incomplete and confined to the lip.
 Good feeding patterns can be established with soft bottles
and modified teats.
Feeding(Contd)
 Simple measures, such as enlarging the hole in the teat,
often suffice.
 Feeding plates, constructed from a dental impression of
the upper jaw, are rarely necessary to improve feeding.
Airway
 Hypoxic episodes during sleep and feeding.
 Intermittent airway obstruction is more frequent and is
managed by nursing the baby prone.
 Persistent airway compromise - ‘Retained nasopharyngeal
intubation’ to maintain the airway.
 Surgical adhesion of the tongue to the lower lip
(labioglossopexy) in the first few days after birth is an
alternative
Delaire timing of cleft surgery
 Unilateral/bilateral cleft lip alone,in one stage operation
done in 4 to 6 months.
 Cleft palate alone involving only soft palate, in one stage
surgery is done in 6 months.
 For cleft palate alone involving both soft & hard palates -
soft palate in 6 months, hard palates in 18 months.
 In combined cleft lip & palate, unilateral or bilateral in 2
stages – cleft lip & soft palate in 6 months, hard palate in
18 months
Treatment for Cleft Lip
Millard criteria used to undertake surgery for cleft lip (Rule
of 10)
 10 kg in weight
 10 weeks old
 10gm% haemoglobin
 Millard cleft repair by rotating the nasolabial flaps
 Management of associated primary or secondary cleft
palate deformity
 Proper post operative management like control of
infection, training for sucking, swallowing & speech
 Tenninson’s Z plasty (Tenninson Randall triangular flap)
Cleft lip surgery
 Skin incisions are developed to
restore displaced tissues,
including skin and cartilage, to
their normal position, while
gaining access to the facial, nasal
and lip musculature.
 Muscular continuity is achieved
by subperiosteal undermining
over the anterior maxilla.
 Nasolabial muscles are anchored
to the premaxilla with nonresorbable sutures.
 Oblique muscles of
orbicularis oris are
sutured to the base of
the anterior nasal spine
and cartilaginous nasal
septum.
 Closure of the cleft lip
is completed by
suturing the horizontal
fibres of orbicularis
oris to achieve a
functioning oral
sphincter.
Cleft palate surgery
 Cleft palate closure can be achieved by one- or two-stage
palatoplasty.
 The surgical principle is mobilisation and reconstruction
of the aberrant soft palate musculature together with
closure of the residual hard palate cleft by minimal
dissection and subsequent scar formation
Principles Of Palatoplasty
 Timing is between 10
-18 months.
 Mucoperiosteum flap
is raised.
 Palatal defect is closed
using 3 layers – nasal,
muscle or oral layers.
 Hook of pterygoid
hamulus is fractured to
relax tensor palate
muscle to relieve
tension on suture line.
 Excess scar formation
in the palate adversely
affects growth and
development of the
maxilla.
 Cleft palate is usually
repaired in 12 to 18 months.
 Early repair causes retarted
maxillary growth- due to
trauma to the growth centre
& periosteum of the maxilla
during surgery if done early.
 Late repair causes speech
defect.
 Both soft & hard palates are repaired.
 Abnormal insertions of tensor palati is released.
 Mucoperiosteal flaps are raised in the palate which is
sewed together.
 If maxillary hypoplasia is present, then osteotomy of the
maxilla is done.
 With orthodontic help teeth extraction & alignment of
dentition is done.
 Regular examination of the ear, nose & throat during
follow up period
 Post operative speech therapy
 Whenever complicated problems are present, staged
surgical procedure is done.
 Wardill Kilner push back operation by raising mucoperiosteal flaps based on greater palatine vessels
Secondary Management
 Hearing support is given using hearing aids.
 Speech problems occur due to velopharyngeal
incompetence, articulation problems also can occurspeech therapy is given.
 It is corrected by pharyngoplasty, veloplasty, speech
devices.